ID

15211

Beskrivning

Routine documentation in German hospitals. Source file name: AM170105_Qualitätssicherungsbogen/ Qualitätssicherung.021 Examplary forms provided by DMI (http://www.dmi.de/)

Länk

http://www.dmi.de/

Nyckelord

  1. 2016-05-22 2016-05-22 -
Uppladdad den

22 maj 2016

DOI

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Licens

Creative Commons BY-NC 3.0

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Quality assurance gall bladders and bile duct diseases Quality assurance sheet Routine documentation in German hospitals DMI

Quality assurance gall bladders and bile duct diseases Quality assurance sheet

Medical history
Beskrivning

Medical history

Alias
UMLS CUI-1
C0262926
Anamnesis
Beskrivning

medical history

Datatyp

text

Alias
UMLS CUI [1]
C0262926
Colics
Beskrivning

colics

Datatyp

boolean

Alias
UMLS CUI [1]
C0232488
Pain in the right upper abdomen
Beskrivning

abdominal pain

Datatyp

boolean

Alias
UMLS CUI [1]
C0000737
Cholestasis
Beskrivning

cholestasis

Datatyp

boolean

Alias
UMLS CUI [1]
C0008370
Diagnostic
Beskrivning

Diagnostic

Alias
UMLS CUI-1
C0086143
Gallstone detection confirmed?
Beskrivning

Gallstones

Datatyp

boolean

Alias
UMLS CUI [1]
C0008350
When yes, confirmed through
Beskrivning

specify

Datatyp

text

X- ray
Beskrivning

X- ray

Datatyp

boolean

Alias
UMLS CUI [1]
C0034571
Ultrasonography
Beskrivning

Ultrasonography

Datatyp

boolean

Alias
UMLS CUI [1]
C0041618
MRCP
Beskrivning

Cholangiopancreatography, Magnetic Resonance MRCP

Datatyp

boolean

Alias
UMLS CUI [1]
C0994163
CT
Beskrivning

CT

Datatyp

boolean

Alias
UMLS CUI [1]
C0040405
ERCP
Beskrivning

ERCP Endoscopic Retrograde Cholangiopancreatography

Datatyp

boolean

Alias
UMLS CUI [1]
C0008310
If ERCP was performed, Biliary Stone Extraction?
Beskrivning

Biliary Stone Extraction

Datatyp

boolean

Alias
UMLS CUI [1]
C1548824
Other
Beskrivning

Other

Datatyp

boolean

Alias
UMLS CUI [1]
C0205394
Acute inflammation
Beskrivning

Acute inflammation

Alias
UMLS CUI-1
C0333361
Acute inflammation
Beskrivning

Acute inflammation

Datatyp

boolean

Alias
UMLS CUI [1]
C0333361
If yes, confirmed through:
Beskrivning

Specify

Datatyp

text

Clinical findings
Beskrivning

clinical findings

Datatyp

boolean

Alias
UMLS CUI [1]
C0037088
Leukocytes > 12000 cells/ mm^2
Beskrivning

Leukocytes

Datatyp

boolean

Alias
UMLS CUI [1]
C0023508
CRP
Beskrivning

CRP

Datatyp

boolean

Alias
UMLS CUI [1]
C0201657
Body temperature (> 38° rectal)
Beskrivning

Body temperature

Datatyp

boolean

Alias
UMLS CUI [1]
C0005903
Ultrasonography
Beskrivning

Ultrasonography

Datatyp

boolean

Alias
UMLS CUI [1]
C0041618
Extrahepatic cholestasis
Beskrivning

Extrahepatic cholestasis

Alias
UMLS CUI-1
C0005398
Extrahepatic cholestasis
Beskrivning

Extrahepatic cholestasis

Datatyp

boolean

Alias
UMLS CUI [1]
C0005398
Confirmed through x- ray
Beskrivning

x- ray

Datatyp

boolean

Alias
UMLS CUI [1]
C0034571
Confirmed through ultrasonography?
Beskrivning

ultrasonography

Datatyp

boolean

Alias
UMLS CUI [1]
C0041618
Confirmed through ERCP?
Beskrivning

ERCP

Datatyp

boolean

Alias
UMLS CUI [1]
C0008310
Confirmed through MRCP?
Beskrivning

MRCP

Datatyp

boolean

Alias
UMLS CUI [1]
C0994163
Confirmed through CT?
Beskrivning

CT

Datatyp

boolean

Alias
UMLS CUI [1]
C0040405
Other
Beskrivning

Other

Datatyp

boolean

Alias
UMLS CUI [1]
C0205394
Information for quality assurance completely collected?
Beskrivning

Documentation

Datatyp

boolean

Alias
UMLS CUI [1]
C0920316
Date of documentaion
Beskrivning

date documentaion

Datatyp

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0920316

Similar models

Quality assurance gall bladders and bile duct diseases Quality assurance sheet

Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
Medical history
C0262926 (UMLS CUI-1)
medical history
Item
Anamnesis
text
C0262926 (UMLS CUI [1])
colics
Item
Colics
boolean
C0232488 (UMLS CUI [1])
abdominal pain
Item
Pain in the right upper abdomen
boolean
C0000737 (UMLS CUI [1])
cholestasis
Item
Cholestasis
boolean
C0008370 (UMLS CUI [1])
Item Group
Diagnostic
C0086143 (UMLS CUI-1)
Gallstones
Item
Gallstone detection confirmed?
boolean
C0008350 (UMLS CUI [1])
specify
Item
When yes, confirmed through
text
X- ray
Item
X- ray
boolean
C0034571 (UMLS CUI [1])
Ultrasonography
Item
Ultrasonography
boolean
C0041618 (UMLS CUI [1])
Cholangiopancreatography, Magnetic Resonance MRCP
Item
MRCP
boolean
C0994163 (UMLS CUI [1])
CT
Item
CT
boolean
C0040405 (UMLS CUI [1])
ERCP Endoscopic Retrograde Cholangiopancreatography
Item
ERCP
boolean
C0008310 (UMLS CUI [1])
Biliary Stone Extraction
Item
If ERCP was performed, Biliary Stone Extraction?
boolean
C1548824 (UMLS CUI [1])
Other
Item
Other
boolean
C0205394 (UMLS CUI [1])
Item Group
Acute inflammation
C0333361 (UMLS CUI-1)
Acute inflammation
Item
Acute inflammation
boolean
C0333361 (UMLS CUI [1])
Specify
Item
If yes, confirmed through:
text
clinical findings
Item
Clinical findings
boolean
C0037088 (UMLS CUI [1])
Leukocytes
Item
Leukocytes > 12000 cells/ mm^2
boolean
C0023508 (UMLS CUI [1])
CRP
Item
CRP
boolean
C0201657 (UMLS CUI [1])
Body temperature
Item
Body temperature (> 38° rectal)
boolean
C0005903 (UMLS CUI [1])
Ultrasonography
Item
Ultrasonography
boolean
C0041618 (UMLS CUI [1])
Item Group
Extrahepatic cholestasis
C0005398 (UMLS CUI-1)
Extrahepatic cholestasis
Item
Extrahepatic cholestasis
boolean
C0005398 (UMLS CUI [1])
x- ray
Item
Confirmed through x- ray
boolean
C0034571 (UMLS CUI [1])
ultrasonography
Item
Confirmed through ultrasonography?
boolean
C0041618 (UMLS CUI [1])
ERCP
Item
Confirmed through ERCP?
boolean
C0008310 (UMLS CUI [1])
MRCP
Item
Confirmed through MRCP?
boolean
C0994163 (UMLS CUI [1])
CT
Item
Confirmed through CT?
boolean
C0040405 (UMLS CUI [1])
Other
Item
Other
boolean
C0205394 (UMLS CUI [1])
Documentation
Item
Information for quality assurance completely collected?
boolean
C0920316 (UMLS CUI [1])
date documentaion
Item
Date of documentaion
date
C0011008 (UMLS CUI [1,1])
C0920316 (UMLS CUI [1,2])

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